Symptoms Of Venous Hypertension Research Articles

Right-Sided May-Thurner Syndrome in a Patient with Left-Sided Inferior Vena Cava and Recent COVID-19 Infection

Background: May-Thurner Syndrome (MTS) is a rare vascular condition where the left common iliac vein is compressed between the right common iliac artery and the spine. We report a case of a patient with a left-sided inferior vena cava and right-sided May-Thurner syndrome. He had recent symptomatic COVID infection despite vaccination (Janssen). Case: A 28-year-old male presented with right lower extremity pain and swelling for three weeks. A duplex ultrasound was performed revealing iliofemoral deep vein thrombosis. Pharmacomechanical thrombectomy with ultrasound assisted thrombolysis was performed with subsequent femoral venogram and angioplasty of the right common iliac vein. Conclusion: May-Thurner Syndrome often remains underdiagnosed due to the chronic nature of the disease process. The presence of a left-sided IVC leading to right sided MTS with recent COVID-19 infection (and vaccination) was a unique feature of this case. May-Thurner Syndrome should be considered in the differential diagnosis of those present with DVTs or symptoms of venous hypertension.

Lumbar overlordosis — towards the better understanding of the May-Thurner syndrome pathogenesis

Introduction: May-Thurner Syndrome (MTS) is a condition in which the left common iliac vein is compressed by the right common iliac artery, which together with intraluminal vein changes can lead to clinically symptomatic venous outflow obstruction. Patients having such pathology may suffer from symptoms of venous hypertension as well as lower leg deep venous thrombosis. In most of the MTS cases, static and continuous compression is observed which can also lead to the intraluminal spur formation. According to the literature, among the factors which can influence the severity of iliac vein compression, lumbar spinal degeneration can also be mentioned. Considering the aortic bifurcation anatomical conditions, also other, non — degenerative changes of the lumbar vertebral column segment can be taken into consideration. Aim: This study aimed to reveal the prevalence of the left common iliac vein compression in young healthy individuals as well as to assess the severity of the left iliac vein compression provoked by lumbar hyperlordosis. Material and methods: The study was performed on a group of 207 volunteers of both sexes, aged 21–27 yrs. using ultrasound examination to measure the diameter of the right common iliac vein as well as the diameter of the left common iliac vein in the area of the possible compression by the right iliac artery. In all the patients the measurements were performed in the supine position as well as in the provoked lumbar hyperlordosis position. In all the individuals the presence of the symptoms and signs of the lower leg chronic venous disease were investigated. Results: The mean anterior-posterior diameter of the right common iliac vein in the standard supine position in the whole study group was 5.71 mm (± 0.6 mm). The mean diameter of the left common iliac vein in a normal horizontal position was 4.87 mm (± 0.6 mm) with a range from 3.8 mm to 6.2 mm. In most of the cases, the difference between the left and iliac common vein diameter (when measured in the place of the right iliac artery crossing) did not exceed 20%. In 15.9% of the study subjects, the right and left iliac vein diameter difference ranges between 20–30% and in 2.41% only, the diameter difference over 30% was noticed (in none of the cases the stenosis exceeding 40% of the vein diameter was found). Looking for the effect of the overlordosis on the proclivity to decrease left iliac vein diameter, in the provoked hyperlordosis position the changes of the iliac vein diameter in the range of 21–30% were observed in 15.9% and over 30% in 2.4% of the study subjects. Hyperlordosis presence was also responsible for the shift towards lower left iliac vein diameter — in 36.2% of the patients, the left iliac vein diameter below 4 mm was noticed including 1.9% of individuals with a diameter not exceeding 3 mm. In the analysis, there was no statistically significant correlation between the presence of the reported CVD symptoms in the left leg and the reported diameter reduction between the right and left iliac veins in the population of the studied young individuals. Conclusions: Left common iliac vein compression may be anatomically conditioned at least in some of the young population individuals. Lumbar hyperlordosis influence on the left common iliac vein diameter suggests that also in healthily individuals, an incorrect spinal position can promote the occurrence of the left iliac vein compression. Further studies are needed to assess the haemodynamic influence of these findings on the lower leg venous outflow.

Microsurgical Management of a Marginal Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video.

Dural arteriovenous fistulas (DAVFs) are benign but may present with life-threatening hemorrhage or symptoms of venous hypertension (eg, progressive myelopathy).1-3 DAVFs follow well-described anatomic patterns.4 The marginal sinus is located between the layers of the dura, circumferentially around the foramen magnum. It communicates with the basal venous plexus of the clivus anteriorly and the occipital sinus posteriorly.5,6 Arterial supply to the dura in this region that fistulizes into the sinus arises from meningeal branches from the V3 or V4 segments. A man in his early 70s presented with chronic neck pain and new onset of left arm and face paresthesias. He had brisk patellar reflexes bilaterally and a marginal sinus DAVF, with numerous dilated veins around the cisterna magna, causing dorsal cervicomedullary compression. Angiography confirmed the diagnosis of DAVF rather than arteriovenous malformation. Endovascular embolization was considered, but surgery was preferable because of poor transarterial access. The patient underwent left far lateral craniotomy and C1 laminectomy with exposure of the condylar fossa. The dura was carefully elevated laterally, revealing a network of dilated tortuous veins, with multiple points of fistulous connection within the dura emanating in a large venous varix. Indocyanine green videoangiography showed the aberrant flow dynamics. The fistulous point was occluded with aneurysm clips on the venous side, then cauterized and interrupted. The patient was discharged within 3 d of surgery and had full resolution of symptoms at 6 wk. Angiography confirmed complete obliteration of the DAVF. The patient provided written informed consent for treatment. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Endovasal laser obliteration of arteriovenous fistulas in patients on chronic hemodialy

Introduction. Vascular access complications are associated with about 30% of patient hospitalizations, and annual costs of vascular access maintenance account for 14–20% of total healthcare costs for dialysis patients. At the same time, current international clinical guidelines emphasize the need to implement a patient-centered approach with planning of possible vascular access complications and selection of optimal surgical interventions (risk/benefit balance) for correction of compromised access.Aim. To present the first experience of endovasal laser obliteration of arteriovenous fistulas for correction of venous hypertension syndrome.Materials and methods. The first experience of complicated arteriovenous fistulas liquidation using endovasal laser obliteration in 6 patients receiving hemodialysis replacement therapy for stage 5 chronic kidney disease (National kidney Foundation (NkF) classification) is presented. In 5 patients due to the presence of venous hypertension of the upper extremity, where the arteriovenous fistula functioned, open intervention was unacceptable because of the high risk of bleeding. In one patient the arteriovenous fistula was closed due to its aneurysmatic transformation. we performed endovasal laser obliteration of four Cimino-type radial artery-cephalic arteriovenous fistulas, one brachial-basilar arteriovenous fistula, and one brachial-cubital arteriovenous fistula. Endovasal laser obliteration was performed with an endovascular light guide under ultrasound navigation using tumescent anesthesia. we used a laser device with a wavelength of 1.56 µm and power of 15 w, working in continuous mode (time 2–4 min, energy density 500 to 1,000 J/cm). The average diameter (Me) of the fistula vein was 8 mm.Results. The course of the early postoperative period in all patients was uncomplicated. The follow-up period was 30 days. Symptoms of venous hypertension were eliminated in all patients, the pain syndrome disappeared completely, there were slight feelings of heaviness and fullness of the limb.Discussion. Experience has shown that standard modes used for varicose vein obliteration for elimination of arteriovenous fistulas in chronic renal failure are ineffective: under conditions of blood flow in the area of arteriovenous anastomosis the energy density is almost 10 times higher. Therefore, other modes were used in our study: energy density from 500 to 1,000 J/cm. This was due to the lack of coagulation of the fistula vein when using standard parameters due to high blood flow rate, despite the use of proximal and distal vascular compression. In all cases we obtained positive results (obliteration of arteriovenous fistulas) without complications along with the correction of venous hypertension within 1 month after the intervention.Conclusion. The advantages of this method are technical simplicity and minimal blood loss, which is especially important for this cohort of patients with initial anemia against chronic renal failure.

Endovascular Embolization in Problematic Hemodialysis Arteriovenous Fistulas: A Nonsurgical Technique.

Introduction:In the past, surgical techniques were considered gold standard practice for obliterating the accessory veins, reducing the flow across the high flowing arteriovenous fistulas (AVFs), or for closing the problematic hemodialysis AVFs. However, recently endovascular embolization has emerged as a safe and cost-effective alternative to these surgical techniques. In this study, technical and clinical success, and safety of endovascular embolization have been evaluated for accessory vein obliteration, flow reduction, and fistula closure in problematic AVFs using various embolizing agents.Methods:This is a retrospective study of patients with problematic hemodialysis AVFs, who underwent endovascular embolization for accessory vein obliteration, flow reduction, and AVF closure at our center from February 2017 to January 2019 with various embolic agents like vascular plugs (VP), thrombin, coils, and glue. Follow-up was done at 1 week, 3 months, 6 months, and annually thereafter.Results:In this study 30 patients with problematic hemodialysis AVFs [Left brachiocephalic fistula (BCF) (n = 22), right BCF (n = 4), and left radiocephalic fistula (RCF) (n = 4)], underwent endovascular embolization for accessory vein obliteration (n = 6), flow reduction (n = 3), and AVF closure (n = 21). Of the 6 patients undergoing embolization for obliteration of accessory collateral, 4 patients had nonmaturing AVFs and 2 patients had symptoms of venous hypertension (VH). Post embolization, all 4 AVFs matured over a month and symptoms of VH completely resolved within a week. Three patients who underwent embolization for flow reduction had patent AVF (on doppler) post procedure and they achieved adequate flow during dialysis with complete resolution of symptoms of VH. Out of 21 patients, who underwent endovascular closure, complete AVF thrombosis was seen in 18 patients only with the use of VP, while 4 patients required additional procedure to achieve complete thrombosis of AVF.Conclusion:Endovascular embolization in problematic hemodialysis AVF is a safe and cost-effective alternative to open surgical methods and vascular plug could be embolic agent of choice for AVF closure.

Endovascular management of central venous occlusive disease in hemodialysis patients with symptomatic venous hypertension

Aim The aim was to evaluate the feasibility and efficacy of balloon angioplasty in hemodialysis patients with venous hypertension. Materials and methods A prospective study was carried out from April 2017 to October 2019 at 6 October Insurance Hospital, Cairo, and Sohag University Hospitals on 32 patients with end-stage renal disease on hemodialysis complaining of venous hypertension owing to central vein occlusive disease treated with balloon angioplasty with or without stenting. Bailout stent was deployed in cases of significant residual stenosis more than 30% or venous recoil. Results The commonest site of central vein occlusion was the innominate vein in 21 (65.6%) patients. Technical success was achieved in 26 (81.3%) patients; 20 of them operated by balloon angioplasty and six achieved after stent deployment. Technical failure occurred in six (18.8%) patients. Overall primary patency rate was 76.9, 57.7, and 46.2% at 3, 6, and 12 months, respectively. Primary patency rate was 80, 65, and 55% at 3, 6, and 12 months, respectively, in those treated with balloon angioplasty, whereas it was 66.6, 33.3, and 33.3% at 3, 6, and 12 months, respectively, in those treated with stent deployment (P=0.17). Reocclusion was recorded in 14 (53.8%) of 26 patients; nine of them were previously managed by balloon dilatation, whereas the other five patients were previously managed by stent deployment. Of 14 cases, 7 were managed successfully by balloon dilatation, 2 of 14 patients were treated by stent deployment, whereas in 5 of 14 cases, revascularization failed. Analysis of data of failed cases denoted that 4/5 of them were in-stent occlusions and one case occluded after percutaneous angioplasty. Conclusion Balloon angioplasty for central vein occlusive disease in hemodialysis patients achieves comparable patency rates and clinical outcomes to venous stent. Although it achieves short-term durability, it should be applied firstly reserving the venous stent for significant residual stenosis.

Efficacy of stent-graft placement to salvage central vein stents with recalcitrant restenosis in patients with arteriovenous fistulas.

The purpose of this study was to determine the effectiveness and permanency of stent-graft placement to salvage stents with recalcitrant restenosis due to central vein stenosis (CVS). Between May 2014 and February 2016, VIABAHN stent-grafts were deployed in patients with functioning arteriovenous (AV) fistulas who underwent previous bare metal stent (BMS) placement and had recalcitrant stent restenosis that did not respond to percutaneous transluminal angioplasty (PTA). Surveillance was carried out at 3, 6, 12, 18, and 24months with diagnostic fistulography. Fourteen patients initially underwent 15 BMS placements. In the follow-up period (range, 118-976days), patients presented with symptomatic venous hypertension; subsequently, a total of 52 unsuccessful repeat PTAs for BMS restenosis were undertaken, and the median primary access survival of PTAs was 66±43days. For salvage, 14 stent-grafts were placed in segments with recalcitrant restenosis of a CVS stent. Within 1.25±0.72days after stent-graft placement, patients who initially presented with symptomatic venous hypertension reported complete resolution. The median primary access survival (mean, 1183±312days) was longer than PTAs alone (P<.01). No major or minor complications were associated with stent-graft deployment or any of the subsequent interventions in the study period. The primary patency rate at 6, 12, and 18months was 100%, and it was 85.7% at 24months. The secondary access patency rate was 92.9% at 24months. In conclusion, stent-graft placement to salvage CVS stents with recalcitrant restenosis in patients with AV fistulas is safe and effective if PTAs fails to maintain luminal patency.

Surgical management of central venous occlusive disease in hemodialysis patients

Background Central venous disease is a common and complex problem that compromises functioning access in patients undergoing hemodialysis which may result in loss of the access. Prior ipsilateral insertion of central venous catheters is a common risk factor. Percutaneous angioplasty with or without stenting is considered the primary method to treat central venous stenosis. However, it carries poor long-term patency rates and require multiple and repetitive interventions. Surgical options could be the choice if endovascular approaches are refractory or impossible. Aim The purpose of this retrospective, observational study is to report our experience in the surgical management to maintain hemodialysis access compromised by venous hypertension (VHTN) due to central venous occlusive disease. Patients and methods This is a retrospective analysis of 14 patients with existing upper extremity hemodialysis access who underwent extra-anatomic surgical bypass to treat symptomatic VHTN due to central vein occlusive disease after failure of endovascular management. Results Technical success was achieved in the 14 (100%) cases while clinical success occurred in 13 (92.6%) cases; 12 (85.7%) patients had performed their hemodialysis sessions via their preexisting access within 24 h postprocedurally. Maximum postoperative hospital stay was 3 days. No in-hospital morbidity or death was recorded. The mean primary and secondary patency were 18.3 and 22.7 months, respectively. Primary patency rates at 6, 12, 18, and 24 months were 85, 78, 64, and 57%, respectively. Secondary patency rates at 6, 12, 18, and 24 months were 92, 85, 71, and 64%, respectively. Conclusion Extra-anatomic surgical bypass of central venous obstruction is an effective and safe method to provide symptomatic relief of VHTN and salvage of existing access in hemodialysis patients when endovascular solutions are unfeasible.

Percutaneous intervention for restoration of patency of occluded lower limb arteriovenous dialysis access

BackgroundArteriovenous (AV) fistula thrombosis is a serious complication in patients undergoing hemodialysis, often presenting with symptoms of venous hypertension, failure to dialysis and uremic symptoms. Treatment is aimed to provide symptomatic relief and to maintain hemodialysis access site patency. AimTo describe our initial experience in the endovascular treatment of lower limb AV dialysis access (AV fistula) thrombosis and/or obstruction in patients undergoing hemodialysis. Settings and designThis was a retrospective study carried out in a tertiary care center. Study duration was 24 months. Follow-up was variable. Materials and methodsTwo patients with chronic kidney disease with stage 5 renal failure undergoing hemodialysis presented with lower limb arteriovenous dialysis access (arteriovenous fistula) failure between July 2014 and September 2016. Both the patients underwent endovascular treatment and were analyzed retrospectively. Results and conclusionBoth the patient underwent successful endovascular treatment for the failure of the lower limb AV dialysis access thrombosis and/or obstruction. One patient had minimal dye extravasation during manipulation of the guide wire, which ceased spontaneously. On follow-up, both patients maintained patency of the dialysis access and are undergoing successful hemodialysis. One patient had a recurrence of the thrombosis of the fistula at 9th month of the follow-up. Endovascular treatment was tried but we could not succeed. However, we found endovascular treatment safe and effective in treating AV fistula failures.

PC132. Using Cephalic or Axillary Vein to Femoral Vein Bypass as Surgical Treatment of Symptomatic Venous Hypertension in Dialysis Patients With Central Venous Occlusion

PC132. Using Cephalic or Axillary Vein to Femoral Vein Bypass as Surgical Treatment of Symptomatic Venous Hypertension in Dialysis Patients With Central Venous Occlusion

Endovascular treatment of central venous obstruction as a complication of prolonged hemodialysis - Preliminary experience in a tertiary care center.

Background:Central venous disease is a serious complication in patients undergoing hemodialysis, often presenting with symptoms of venous hypertension. Treatment is aimed to provide symptomatic relief and to maintain hemodialysis access site patency.Aim:To describe our initial experience in the endovascular treatment of central venous stenosis or obstruction in patients undergoing hemodialysis.Settings and Design:This was a retrospective study carried out in a tertiary care center. Study duration was 24 months. Follow-up was variable.Materials and Methods:Eleven patients of chronic renal failure undergoing hemodialysis presented with central vein stenosis or obstruction having ipsilateral vascular access, between July 2012 and July 2014. All the patients underwent endovascular treatment and were analyzed retrospectively.Results and Conclusion:A total of 11 patients (4 male and 7 female) underwent 18 interventions for 13 stenotic segments during a time period of 2 years. Eight stenotic segments were in brachiocephalic vein, three in subclavian vein, and two in axillary veins. The technical success rate for endovascular treatment was 81.8%. Two patients underwent percutaneous transluminal angioplasty (PTA) alone and presented with restenosis later. Balloon angioplasty followed by stenting was done in seven patients, two of which required reintervention during follow-up. We found endovascular treatment safe and effective in treating central venous disease.

Computed Tomograpy Venography diagnosis of iliocaval venous obstruction in advanced chronic venous insufficiency

Objective:Iliocaval obstruction is associated with venous hypertension symptoms and may predispose to deep venous thrombosis (DVT). Ultrasonography may fail to achieve noninvasive diagnosis of these obstructions. The possibility of using Computed Tomography Venography (CTV) for these diagnoses is under investigation.Methods:Patients with CVI graded at CEAP clinical classes 3 to 6 and previous treatment failure underwent evaluation with CTV. Percentage obstruction was rated by two independent examiners. Obstruction prevalence and its associations with risk factors and CEAP classification were analyzed.Results:A total of 112 limbs were prospectively evaluated. Mean patient age was 55.8 years and 75.4% were women. Obstructions involved the left lower limb in 71.8% of cases and 35.8% of patients reported a medical history of deep venous thrombosis. Overall, 57.1% of imaging studies demonstrated venous obstruction of at least 50% and 10.7% showed obstruction of &gt;80%. The only risk factor that was found to be independently associated with a significantly higher incidence of &gt;50% venous obstruction was a medical history of DVT (p=0.035) (Fisher's exact test). There was a positive relationship between clinical classification (CEAP) and degree of venous obstruction in the limbs studied (Chi-square test for linear trend; p=0.011).Conclusion:Patients with advanced CVI are often affected by obstructions in the iliocaval venous territory and CTV is able to diagnose the degree of obstruction. There is a positive association between degree of obstruction and both previous history of DVT and severity of symptoms of CVI.

Transposition of cephalic vein to rescue hemodialysis access arteriovenous fistula and treat symptomatic central venous obstruction

It is known that stenosis or central venous obstruction affects 20 to 50% of patients who undergo placement of catheters in central veins. For patients who are given hemodialysis via upper limbs, this problem causes debilitating symptoms and increases the risk of loss of hemodialysis access. We report an atypical case of treatment of a dialysis patient with multiple comorbidities, severe swelling and pain in the right upper limb (RUL), few alternative sites for hemodialysis vascular access, a functioning brachiobasilic fistula in the RUL and severe venous hypertension in the same limb, secondary to central vein occlusion of the internal jugular vein and right brachiocephalic trunk. The alternative surgical treatment chosen was to transpose the RUL cephalic vein, forming a venous necklace at the anterior cervical region, bypassing the site of venous occlusion. In order to achieve this, we dissected the cephalic vein in the right arm to its junction with the axillary vein, devalved the cephalic vein and anastomosed it to the contralateral external jugular vein, providing venous drainage to the RUL, alleviating symptoms of venous hypertension and preserving function of the brachiobasilic fistula.

Anatomical factors associated with left innominate vein stenosis in hemodialysis patients

Central venous stenosis remains a challenge in hemodialysis patients. Venograms have shown that left innominate vein (LIV) stenosis often occurs in front of the trachea, where it crosses the aortic arch, suggesting that there may be an anatomical factor involved, such as iliac vein compression syndrome. The goal of this study was to determine whether LIV stenosis can be attributed to compression. From September 2008 to December 2011, 19 hemodialysis patients (ten women, nine men) with symptomatic venous hypertension of the upper-left extremity were enrolled in this study. Venography and multidetector computed tomography were used to determine the location of the venous stenosis and to assess LIV anatomy. LIV diameter and the space between the sternum and aortic arch were compared between the LIV stenosis (LIVS) group (n = 9) and the non-LIV-stenosis (NLIVS) group (n = 10). The mean age of the cohort was 63 ± 17.3 years. The mean LIV diameter was 1.69 ± 1.55 mm in the LIVS group and 8.71 ± 2.33 mm in the NLIVS group. The space between the aortic arch and sternum was smaller in the LIVS group (4.55 ± 2.67 mm) than in the NLIVS group (15.25 ± 6.12 mm, P < 0.001). A contributing factor to LIV stenosis may be due to anatomical compression of the aortic arch behind the sternum. Preoperative noncontrast computed tomography is recommended for hemodialysis patients to exclude extrinsic compression.

Human Chronic Post-Thrombotic Intraluminal Venous Obstruction Involves Neovascularization.

or venography. When findings are “normal,” the physician is left with no explanation for recurrent venous hypertension. The purpose of this study is to show the value of looking inside the stent, with intravenous ultrasound (IVUS), to identify treatable hemodynamically significant lesions that cause symptomatic venous hypertension. Methods: Patients underwent standard measurements of limbs, duplex of lower extremities and iliac veins with attention to waveform analysis and velocities. Symptomatic patients were imaged from a jugular or popliteal approach with multi-plane venography and IVUS, to evaluate the stents and veins. In the event of in-stent stenosis, measurements of cross-sectional area were obtained before and after intervention. Treatment included angioplasty, atherectomy, or strategic placement of a new stent. Procedures were performed on an outpatient basis. No change of therapeutic international normalized ratio for patients on warfarin. A postprocedure duplex was performed and compared to the preoperative study. Results: Between 2002 and 2013, we evaluated 37 patients (17 M, 20 F) with 47 limbs (17 R, 30 L; 9 bilateral + 13 inferior vena cava) with previously placed iliocaval venous stents. Each person presented with new onset pain and/or edema that had been absent after initial stenting. The onset of recurrent venous hypertension ranged between 6 months and 10 years. Twenty-seven of 47 limbs had occluded stents, while 20 of 47 had one or more stenoses. The mean age was 41.4 years (range, 21-70 years). Lumen-compromising stenosis was identified within stents, with IVUS, in 90% of symptomatic patients, all of whom had “normal” findings on duplex. Tissue specimens were obtained in three cases, and evaluation showed fibrosis, not thrombus. Balloon dilatation effectively increased luminal area. Recalcitrant lesions (4) were successfully enlarged with balloonexpandable nitinol stents. Sustained patency of the revisions has been excellent. Mean follow-up was 38 months. All patients reported clinical improvement consistent with decreased venous pressure. Conclusions: Patients with failing venous stents present with recurrent limb edema or pain, heaviness, tightness, etc. Hyperplasia can narrow the diameter up to 30% and not be appreciated with standard duplex or venography. Restenosis typically occurs, circumferentially, where stents overlap and at the leading edges. IVUS is an important tool for investigating stent integrity in symptomatic patients. Timely endovenous evaluation and treatment of failing stents is clinically indicated to preserve patency.

Endovascular treatment of central venous stenosis and obstruction in hemodialysis patients

Background Central venous stenosis and obstruction (CVD) is a serious and prevalent challenge to both resolve the venous hypertension symptoms and maintain the pantency of the ipsilateral hemodialysis access in hemodialysis patients. This study aimed to summarize our experience of the endovascular management of the central venous stenosis or obstruction in hemodialysis patients. Methods Twenty-four haemodialysis cases of central vein stenosis or obstruction with ipsilateral functional vascular access in our hospital between July 2006 and February 2012 were treated by interventional therapy and the data were analyzed retrospectively. Results Eighteen males and six females with mean age of (66.4±13.8) years and manifesting with arm swelling and venous hypertension were enrolled; 62.5% of them had a history of catheterization. Venography showed stenotic lesion in 10 cases including eight cases of brachiocephalic vein stenosis and two cases of subclavian vein stenosis and 14 cases of obstruction lesions including seven cases of short brachiocephalic obstruction and seven cases of long segment obstruction. Interventional therapy was performed and the technique success rate was 83.3%. Percutaneous transluminal angioplasty (PTA) was performed in nine cases and stent was performed in 11 cases firstly. The symptoms of venous hypertension were resolved after intervention in all the cases. There was no major complication and death perioperatively. During follow-up, reintervention was done, the primary patency rates were (88.9±10.5)%, (64.8±10.5)% and (48.6±18.7)% at 3 months, 6 months and 1 year after treatment in the PTA group; (90.0±9.5)% and (77.1±14.4)% at 6 months and 1 year after treatment in the stent group, respectively. The secondary patency rates were (48.6±18.7)% in the PTA group and (83.3±15.2)% in the stent group 1 year after treatment, respectively. There was no significant difference between the two groups (primary patency, P=0.20; secondary patency, P=0.10). Conclusions The endovascular intervention is a safe and effective method for CVD in short term; enhanced follow-up and repeated interventions are required to maintain patency for long term. The prevention is most important. Avoiding and minimizing the placement of the central venous catheter may be the key point for the prevention.

Developmental Venous Anomaly Associated with Hemi-Parkinson’s Syndrome

Objective and Importance: Developmental venous anomalies (DVAs) are common congenital anomalies of intracranial venous drainage. In general, it is felt that DVAs replace the normal venous drainage system and, unless associated with another lesion such as a cavernous malformation, should not produce symptoms. The present case raises important questions regarding the potential for DVAs to become symptomatic and the role of venous hypertension in this process. Clinical Presentation: We present the case of a 23-year-old woman who presented with rapidly progressive hemi-parkinsonism consisting of unilateral tremor, micrographia, gait difficulty, and cogwheel rigidity. MRI demonstrated a large DVA draining the region of the contralateral basal ganglia with associated high signal intensity on T2-weighted MR imaging and gadolinium enhancement. Arteriography demonstrated only the DVA with the trunk of the angioma draining forward toward the inferior petrosal sinus instead of into the deep venous system. A focal stricture of the main venous trunk was noted. Retrograde venography confirmed a tight stricture at the entrance of the venous trunk into the cavernous sinus. Conclusions: Although DVAs are generally considered benign variants of normal venous drainage, it is possible that in select cases, venous outflow restriction may result in symptomatic venous hypertension. This may be particularly problematic in the setting of a large DVA when multiple radicular veins drain into a single large venous channel.

Venöses Aneurysma als therapeutisches Problem. Behandlungsmöglichkeiten. Die Vorgehensweise bei den gewählten Kranken – unsere Erfahrung

Venous system aneurysms appear relatively rarely, and are even more rarely diagnosed, especially if asymptomatic. In the material of our clinic we provide a variety of practices in three patients with venous aneurysms depending on the location, symptoms and main disease. In some patients the occurrence of pulmonary embolism is the first symptom of venous aneurysms, having influence on the selection of further diagnostics, conservative treatment, as well as on endovascular or operating procedure. The proper diagnosis of a venous aneurysm takes place in case of doubling or tripling of the diameter of the basic dimension of the lumen, often with the presence of thrombotic material. Asymptomatic venous aneurysms are usually detected during routine pre-operative diagnosis also including duplex-Doppler studies. In the presence of pulmonary embolism positive angio-CT and scintigraphy raise the suspicion of venous aneurysm unless any other reason is apparent. There is no standard treatment of venous aneurysms. This has to do with the relatively low epidemiology, diversity of location, difficulties in determining the proper primary and secondary aetiology, anatomy and coexisting diseases. Despite the many unknowns a few issues should be considered before appropriate treatment is undertaken. Undoubtedly, the shape itself, the location and size of the aneurysm with the presence or not of thrombotic material are of great value in evaluating the risk of complications, including possibly lethal pulmonary embolism, local symptoms of venous hypertension and possible complications of surgery. In this paper we present 3 patients treated for venous aneurysms located in different regions: popliteal vein, brachial vein and iliac internal vein.

Asymptomatic spinal dural arteriovenous fistulas: pathomechanical considerations

Spinal dural arteriovenous fistulas (SDAVFs) consist of a shunt with converging feeding vessels arising from radiculomeningeal arteries and draining retrogradely via a radicular vein into the perimedullary veins, thereby causing progressive myelopathy due to venous hypertension in the spinal cord. The purpose of this study was to evaluate the hypothesis that the obstruction of radicular venous outlets could be an additional factor inducing symptomatic venous hypertension due to a decreased outflow in SDAVFs. The authors compared the clinical and imaging findings in patients with asymptomatic SDAVFs identified incidentally at the upper thoracic region with the findings in symptomatic patients who harbored SDAVFs at the same level. All symptomatic patients presented with medullary dysfunction. The mean age of patients with asymptomatic SDAVF was 51.5 years, approximately 10 years younger than the patients with symptomatic SDAVF (64.1 years old). Despite the existence of dilated perimedullary vessels in the dorsal side of the spinal cord in all patients, the spinal cord edema seen in symptomatic patients was not detected on the MR images obtained in patients with asymptomatic SDAVF. The spinal angiograms of the asymptomatic patients distinctively demonstrated early radicular venous outflow from affected perimedullary veins to the extradural venous plexus as a potential alternate route for the venous hypertension to be released. Obstruction of the radicular venous outflow could be an important factor in inducing spinal congestive edema due to venous hypertension, as well as subsequent clinical symptoms of SDAVFs.

Venous leg ulceration and graduated compression

Venous leg ulceration is the most common type of ulceration. Incompetency of the valves in the leg results in raised venous pressure which gives rise to the signs and symptoms of venous hypertension. The application of compression bandage therapy remains the cornerstone of treatment in the healing of venous leg ulceration. Application of the correct level of pressure to reverse venous hypertension is essential for such therapy to be successful and practitioners need to be trained in assessment and application techniques to ensure that the recommended level of pressure is applied without causing adverse problems and risks to the patient.